Provider Demographics
NPI:1467805390
Name:EVANS, BRYCE ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:ALAN
Last Name:EVANS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W NIFONG BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5615
Mailing Address - Country:US
Mailing Address - Phone:573-874-1990
Mailing Address - Fax:573-874-1923
Practice Address - Street 1:1000 W NIFONG BLVD STE 130
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5615
Practice Address - Country:US
Practice Address - Phone:573-874-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016021053122300000X, 1223P0221X
IADDS-098711223P0221X
IA30487390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program